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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002969
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:13:05 AM


Document Has Been Signed on 11/30/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:EZE CAREHOMEFACILITY NUMBER:
345002969
ADMINISTRATOR:NINOBLA, ROJEL DANFACILITY TYPE:
740
ADDRESS:1123 NEWPORT WAYTELEPHONE:
(650) 307-2090
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
11/30/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rojel Ninobla- AdministratorTIME COMPLETED:
11:15 AM
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On 11/30/2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator, Rojel Ninobla, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. LPA were screened by Administrator prior entering the facility.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and three (3) bathrooms. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed at 110 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPA observed sharps/ knives to be locked away and inaccessible to residents in care. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents.

LPA observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. The care home has smoke detectors and carbon monoxide detectors that are operable. Licensing complaint poster are posted as required. Fire extinguishers and first aid kit are maintained and ready for emergency use.

Component III presentation conducted with administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit Interview conducted and copy of report provided.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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